Open Cranial Vault Reconstruction Research Articles

Scoping Review of Healthcare Disparities in Treatment of Craniosynostosis: Assessing Impacts of Race, Insurance, and Socioeconomic Status

Background: Racial and socioeconomic factors persist as barriers to timely diagnosis and treatment for children with craniosynostosis, contributing to inequitable care. This scoping review aims to better understand how disparities influence differences in services, approach, and outcomes for patients undergoing surgical corrections for craniosynostosis. Methods: We conducted a PRISMA systematic review of all articles published between 2003 and 2023 within PubMed/Medline, Embase, and a Scopus cited review. Variables of interest included sociodemographic factors such as race, socioeconomic status (SES), and insurance status, and measurements of treatment access or outcomes within craniosynostosis surgical repair. Results: The final analysis included 28 studies, of which 21 studies examined race, 13 examined insurance status, and 5 examined household income or other socioeconomic factors. Overall, non-White, minority patients, patients with Medicaid or government-funded insurance, and patients from lower SES were more likely to experience delays in diagnosis and presentation for surgery compared to White and privately-insured patients. Black and Hispanic patients and patients with public insurance were more likely to undergo open cranial vault reconstruction (CVR) at an older age and experience longer total surgery time, increasing perioperative complication risk, compared to patients who underwent endoscopic procedures. Sociodemographic factors including non-White race, lower SES, and being underinsured or uninsured predisposed patients to the more expensive CVR procedure, increased hospital length of stay (LOS), and a higher rate of readmission, accumulating to greater total cost of care. Conclusion: Significant disparities continue to exist in craniosynostosis management. It is still unknown whether these discrepancies in the type of operation lead to significant clinical differences in neurocognitive outcomes, revision operations, or patient/parent satisfaction with appearance. This study highlights gaps in the current body of knowledge to better inform future aeas of investigation to ensure the best outcomes for all children born with craniosynostosis regardless of patient demographic.

Evaluating Tranexamic Acid Administration in Cranial Vault Reconstruction: The Experience of an Academic Center in the Deep South

Background: In infants with craniosynostosis, cranial vault reconstruction is performed to prevent sequela of premature fusion of cranial sutures. Open correction puts patients at risk for complications of major blood loss. We evaluated the impact of tranexamic acid (TXA) in children undergoing open surgical repair of a variety of types of craniosynostosis. Methods: A retrospective review of 102 infants who underwent open cranial vault reconstruction between January 2015 and December 2020 at a tertiary referral hospital was performed. The patients were stratified into TXA or non-TXA based on usage. Outcome measures included volume of blood transfused, perioperative blood loss and any adverse effects were noted. Results: In this cohort 42% of patients were treated with TXA. There was no significant difference between the patient demographics of TXA and non-TXA cohorts with the majority classified as Sagittal Craniosynostosis ( P = .1062), an average weight of 8.89 ± 1.37 kg, and age of 9.02 ± 2.02 months at time of surgery. The non-TXA cohort had longer length of hospital stay ( P = .04). The TXA cohort had an average 100 ml decrease in surgical drain output over the course of their hospital stay ( P = .02). Overall surgical complication was 14% ( P = .18) and clinical outcomes were not significantly different between the cohorts. Conclusions: The receipt of TXA in the interoperative period in patients with craniosynostosis undergoing cranial vault remodeling was associated with a decreased surgical drain output and length of stay.

Longitudinal Three-Dimensional Follow-Up and Secondary Treatment Aspects after Endoscopic and Open Scaphocephaly Surgery.

This retrospective cohort study evaluated the longitudinal three-dimensional cranial shape developments and the secondary treatment aspects after endoscopically assisted craniosynostosis surgery (EACS) with helmet therapy and open cranial vault reconstruction (OCVR) for scaphocephaly. Longitudinally collected three-dimensional photographs from scaphocephaly patients and healthy infants were evaluated. Three-dimensional cranial shape measurements and growth maps were compared between the groups over time. Secondary treatment aspects were compared for the treatment groups. Both surgical techniques showed their strongest changes directly after surgery, with mean parietal three-dimensional growths up to 10 mm. At age 24 months, comparison of head shapes showed mean three-dimensional differences less than ±2 mm, with OCVR resulting in a lower vertex and longer cranial length when compared with EACS. At 48 months of age, no measurements were significantly different between treatment groups. Only the total head volume was somewhat larger in the male EACS group at age 48 months ( P = 0.046). Blood loss in EACS (mean, 18 mL; range, 0 to 160 mL) was lower than in OCVR (mean, 100 mL; range, 15 to 300 mL; P < 0.001). Median length of stay after surgery was shorter for EACS (mean, 2 days; range, 1 to 5 days) compared with OCVR (mean, 5 days; range, 3 to 8 days; P < 0.001). The authors conclude that EACS for scaphocephaly shows equal craniometric results at age 48 months and has a better surgery profile compared with OCVR. Early diagnostics and referral for suspected scaphocephaly to allow EACS is therefore recommended. Therapeutic, III.

306 Long-Term Appearance and Outcomes after Strip Craniectomy Compared with Open Cranial Vault Reconstruction for Sagittal Craniosynostosis

OBJECTIVES/GOALS: Strip craniectomy with orthotic helmet therapy (SCOT) and open cranial vault reconstruction (OCVR) are mainstay surgical treatments for sagittal craniosynostosis. The purpose of this study is to compare long-term morphologic outcomes of the skull, subjective appearance, and perioperative outcomes between patients who underwent SCOT and OCVR. METHODS/STUDY POPULATION: Patients who underwent SCOT or OCVR for isolated, non-syndromic sagittal craniosynostosis with preoperative computerized tomography (CT) imaging were identified at UCSF between 2000 and 2020. Perioperative outcomes were extracted from the medical chart. Anthropometric measurements will be used to assess baseline severity using preoperative CT imaging and postoperative skull morphology using 3D camera imaging. Patient satisfaction surveys will be administered to parents at the time of postoperative 3D imaging. Subjective appearance will be rated among adolescents and craniofacial surgeons using patients’ postoperative 3D imaging. Descriptive statistics will be calculated using Student’s t test and Mann-Whitney U. Chi-square tests and Fisher exact tests will be used to compare categorical outcomes. RESULTS/ANTICIPATED RESULTS: 47 patients were included in the study (18 SCOT and 29 OCVR) with similar follow-up between groups (SCOT 2.3 +/- 1.5, OCVR 2.6 +/- 2.0). There were no significant differences in sex or race. OCVR had longer operative times (p-value 0.0003), higher estimated blood loss (p DISCUSSION/SIGNIFICANCE: SCOT was associated with superior perioperative outcomes compared with OCVR due to its minimally invasive technique. Our results for long-term healing outcomes and subjective appearance may further guide craniofacial surgeons in selecting the most optimal operative technique.

The Effect of Tranexamic Acid and Controlled Hypotension on Perioperative Blood Loss in Craniosynostosis Surgery.

Open cranial vault reconstruction is the standard technique of craniosynostosis correction that may cause significant blood loss. The current study aimed at comparing the effect of tranexamic acid (TXA), controlled hypotension, and their combination on perioperative blood loss and transfusion requirement in craniosynostosis surgery. The present randomized, double-blind clinical trial was conducted on 75 infants referred for craniosynostosis surgery during 2017 - 2018. Ten minutes before the start of surgery, 10 mg/kg of TXA was administered intravenously to patients in the first group (TXA group). In the second group, patients were subjected to the controlled hypotension anesthesia (CHA) using intravenous remifentanil 0.1 μ/kg (CHA group). In the third group, the patients underwent CHA similar to that of the second group, along with intravenous injection of 10 mg/kg of TXA (CHA-TXA group). Then, patients' mean arterial pressure (MAP), heart rate (HR), total blood loss, and transfusion volume were evaluated and recorded. The results of the present study revealed that although the changes in MAP and HR parameters over time (three hours after surgery) were significant in all three groups, the lowest decrease was observed in the CHA-TXA group (P-value < 0.05). In addition, the total perioperative blood loss in the CHA-TXA group with the mean of 181.20 ± 82.71 cc was significantly less than the total perioperative blood loss in the CHA and TXA groups with the means of 262.00 ± 104.04 cc and 212.80 ± 80.75 cc, respectively (P-value < 0.05). Moreover, the transfusion volume in the CHA-TXA group with the mean of 112.40 ± 53.50 cc was significantly lower than the transfusion volume in the CHA and TXA groups with the means of 174.00 ± 73.93 cc and 160.63 ± 59.35 cc, respectively (P-value < 0.05). In contrast, the total blood loss and transfusion volume were not significantly different between the CHA and TXA groups (P-value > 0.05). According to the results of the present study, although the administration of TXA alone could effectively prevent blood loss and was associated with fewer transfusion requirements, the combination of this approach with hypotensive anesthesia resulted in more reduction in perioperative blood loss and transfusion volume as well as better hemodynamic stability.

Surgical guides versus augmented reality to transfer a virtual surgical plan for open cranial vault reconstruction: A pilot study

Virtual surgical planning of an open cranial vault reconstruction enables a faster, safer and better surgical procedure for craniosynostosis patients. However, transfer a virtual surgical plan to the patient remains challenging. Although 3D-printed surgical guides can be used, their production is rather time-consuming and expensive. Since augmented reality (AR), allows the user to directly visualize a virtual planning onto the patient, it can be used as an alternative.By using AR-glasses (HoloLens), a new AR-based workflow was developed and compared with surgical guides to transfer the surgical plans on 3D-prints of 10 patients suffering from different types of craniosynostosis.An accuracy of 2.1 mm and a mean transfer time of 8.24 min were reported with the AR workflow as compared to an accuracy of 0.9 mm and a mean transfer time of 50 s for surgical guides.Surgical guides were the most fitting method to transfer virtual surgical plans. The relatively large outliers in the AR workflow meant that the mean accuracy was just outside the clinically acceptable margin. However, the low cost and simplicity make the AR workflow a promising alternative.

Crowdsourcing the Perception of the Bicoronal Scar in Open Cranial Vault Reconstruction

Purpose: Within open cranial vault reconstruction (CVR) for craniosynostosis, efforts have been directed at minimizing the bicoronal scar, which contributes to increased patient stigmatization and decreased parental satisfaction. To understand these esthetic considerations across multiple centers, we evaluated demographic and clinical determinants of patient scar self-consciousness, parental scar satisfaction, and parental satisfaction with their children’s overall medical and surgical care. Methods: A 25-item questionnaire was distributed within an 18 500-member craniosynostosis parental online support group. Parents were asked to grade patient scar self-consciousness, parental scar satisfaction, and parental satisfaction with their children’s overall care on a 10-point Likert scale. A t-test and linear regression were performed for binary and continuous variables. Results: Of 838 responses, 516 met inclusion criteria. 32% of patients had visible scar alopecia and 25% of respondents reported their child’s hair is deliberately styled to disguise the scar. 2% of patients underwent scar revision. Older age, complications, ongoing symptoms, and increased number of surgeries were negatively associated with parental scar satisfaction, patient self-consciousness, and parental satisfaction with overall management. Ethnicity and hair texture were not associated with patient self-consciousness or parental satisfaction with care. Incision type (zig-zag/wavy compared to straight bicoronal incisions) showed no significant difference in subjective outcomes measures or rates of external stigmatizing behavior between the 2 groups. Conclusions: Bicoronal scarring has complex and multifaceted psychosocial effects. Advanced age, complications, ongoing symptoms, and increased number of surgeries are key determinants of patient and parent satisfaction, though parental esthetic satisfaction may be more sensitive to external stigmatizing behavior. This study calls for a reappraisal of conventional teaching regarding the impact of incision design. While craniofacial morphology, neurological development, and social functioning may be more foundational to overall patient and parent satisfaction, the esthetic value of the bicoronal scar should not be undervalued.

Superior Long-term Appearance of Strip Craniectomy Compared with Cranial Vault Reconstruction in Metopic Craniosynostosis.

Background:Strip craniectomy with orthotic helmet therapy (SCOT) is an increasingly supported treatment for metopic craniosynostosis, although the long-term efficacy of deformity correction remains poorly defined. We compared the longterm outcomes of SCOT versus open cranial vault reconstruction (OCVR).Methods:Patients who underwent OCVR or SCOT for isolated metopic synostosis with at least 3 years of follow-up were identified at our institution. Anthropometric measurements were used to assess baseline severity and postoperative skull morphology. Independent laypersons and craniofacial surgeons rated the appearance of each patient’s 3D photographs, compared to normal controls.Results:Thirty-five patients were included (15 SCOT and 20 OCVR), with similar follow-up between groups (SCOT 7.9 ± 3.2 years, OCVR 9.2 ± 4.1 years). Baseline severity and postoperative anthropometric measurements were equivalent. Independent adolescent raters reported that the forehead, eye, and overall appearance of SCOT patients was better than OCVR patients (P < 0.05, all comparisons). Craniofacial surgeons assigned Whitaker class I to a greater proportion of SCOT patients with moderate-to-severe synostosis (72.2 ± 5.6%) compared with OCVR patients with the same severity (33.3 ± 9.2%, P = 0.02). Parents of children who underwent SCOT reported equivalent satisfaction with the results of surgery (100% versus 95%, P > 0.99), and were no more likely to report bullying (7% versus 15%, P = 0.82).Conclusions:SCOT was associated with superior long-term appearance and perioperative outcomes compared with OCVR. These findings suggest that SCOT should be the treatment of choice for patients with a timely diagnosis of metopic craniosynostosis.

Comparing Long-term Outcomes of Open Cranial Vault Reconstruction and Minimally Invasive Strip Craniectomy in Metopic Craniosynostosis

PURPOSE: The gold-standard treatment for metopic craniosynostosis is open cranial vault reconstruction (OCVR) with fronto-orbital advancement. A recent alternative is minimally invasive strip craniectomy with orthotic helmet therapy (SCOT), which has perioperative outcomes superior to those of OCVR, though its long-term efficacy remains poorly defined.1 We sought to compare the long-term morphologic outcomes, patient satisfaction, and subjective appearance in patients with metopic synostosis who underwent OCVR versus SCOT. METHODS: Patients who underwent OCVR or SCOT between 2000 and 2017 for isolated metopic synostosis were identified at our institution. Inclusion criteria included (1) preoperative CT or laser scan imaging, (2) postoperative 3D photos, and (2) at least 3 years of follow-up. Interfrontal angle and interzygomaticofrontal distance measurements were taken from preoperative scans to assess baseline severity.2 Frontal width and intercanthal width, normalized by age and sex, and glabellar angle measurements were made on 3D photos at the latest follow up.2 Independent adolescents and craniofacial surgeons, blinded to the treatment of each patient, rated the appearance of postoperative photos. All patients’ parents completed satisfaction surveys at the latest follow up. RESULTS: Thirty-five patients were included (15 SCOT and 20 OCVR). Mean follow-up time was similar for both groups (SCOT 7.9 ± 3.2 years versus OCVR 9.2 ± 4.1 years, P = 0.33). Baseline severity between groups was similar in both interfrontal angle (SCOT 116.6 degrees ± 8.8 degrees versus OCVR 110.5 degrees ± 10.1 degrees, P = 0.07) and interzygomaticofrontal distance (SCOT 67.5 ± 6.8 mm versus OCVR 66.5 ± 8.6 mm, P = 0.75). Postoperatively, the glabellar angle was equal between groups (SCOT 122.2 degrees ± 4.2 degrees versus OCVR 123.9 degrees ± 6.0 degrees, P = 0.16), as were age- and sex-adjusted frontal width (SCOT Z-score −0.8 ± 1.5 versus OCVR −1.7 ± 1.5, P = 0.09) and intercanthal width (SCOT Z-score 1.2 ± 1.2 versus OCVR 0.5 ± 1.1, P = 0.11). Independent laypersons rated the overall appearance of SCOT patients as equal to that of normal controls (P = 0.31) and better than that of OCVR patients (P = 0.04). Craniofacial surgeons assigned Whitaker class I to a greater proportion of SCOT patients (75.6% ± 6.4%) compared with OCVR patients (43.3% ± 9.5%, P = 0.02), particularly among patients with moderate-severe synostosis (SCOT 72.2% ± 5.6% versus OCVR 33.3% ± 9.2%, P = 0.02). Parents of patients who underwent SCOT and OCVR reported equivalent levels of satisfaction with the appearance of their child’s forehead (93% versus 95%, P > 0.99) and with the overall results of the surgery (100% versus 95%, P > 0.99). Likewise, parents of children who underwent MISC were no more likely to report bullying (7% versus 15%, P = 0.82) or social exclusion (0% versus 15%, P = 0.34) due to their child’s appearance. CONCLUSION: Minimally invasive strip craniectomy with orthotic helmet therapy was associated with equivalent long-term morphologic outcomes and patient satisfaction, and superior subjective appearance, compared with open cranial vault reconstruction among patients with metopic craniosynostosis. REFERENCES: 1. Yan H, Abel TJ, Alotaibi NM, et al. A systematic review of endoscopic versus open treatment of craniosynostosis. Part 2: the nonsagittal single sutures. J Neurosurg Pediatr. 2018;22(4):361–368. 2. Nguyen DC, Patel KB, Skolnick GB, et al. Are endoscopic and open treatments of metopic synostosis equivalent in treating trigonocephaly and hypotelorism? J Craniofac Surg. 2015;26(1):129–134.

Skin Deep: Perception of Scars After Cranial Vault Reconstruction.

Children with craniosynostosis are vulnerable to stigmatization and social withdrawal. Cranial vault reconstruction (CVR) results in large bicoronal scars, which may trigger further insult to self-esteem and social outcasting. This study aimed to delineate determinants of patient scar self-consciousness, parental scar satisfaction, and parent satisfaction with their child's overall medical/surgical care. A 14-item questionnaire was distributed to parents of 95 patients who underwent open CVR at our institution. Age at first surgery, race, hair type, typical style, number of surgeries, complications, and use of distractors were surveyed. Patient scar self-consciousness, parental scar satisfaction, and parent satisfaction with their child's overall medical/surgical care were also queried. T tests and linear regressions were performed for binary and continuous variables, respectively. Of 45 respondents, significant associations were found between: (1) complications and decreased parent scar satisfaction; (2) complications and decreased overall satisfaction with medical/surgical care, and (3) older age at time of initial surgery and decreased overall medical/surgical satisfaction. A significant association was found between parental scar satisfaction and overall medical/surgical satisfaction (β = 0.65, P = .002). There was no significant association between parent scar satisfaction and parental-reported patient self-consciousness, or parental-reported patient self-consciousness and overall medical/surgical satisfaction. Our results underscore the value of scar aesthetics in reconstructive goals. Advanced age and complications are important determinants of satisfaction. However, the lack of association between parent-reported patient self-consciousness and parental scar satisfaction suggests differences in aesthetic priorities between parents and children. Further studies may elucidate additional aesthetic considerations of CVR in ethnic/racial minorities.

Introduction of a ROTEM-assisted strategy improves patient blood management in children undergoing open craniosynostosis repair

Purpose The surgical correction of craniosynostosis by open cranial vault reconstruction (OCVR) is often associated with significant blood loss and perioperative blood transfusion demand. Because of transfusion risks, several attempts have been made to eliminate the need for perioperative homologous blood transfusion with the implementation of goal-directed transfusion protocols. The aim of this study was to determine whether the introduction of a rotational thromboelastometry (ROTEM)–assisted patient blood management strategy would decrease the intraoperative blood transfusion and blood loss levels. Methods Patients younger than 2 years of age who were diagnosed with nonsyndromic single suture synostosis and underwent primary OCVR were investigated in this retrospectively designed cohort study. The children were equally divided into 2 study groups according to the availability of the ROTEM-assisted protocol. The control group had surgery before introduction of the new protocol, whereas the study group was operated on subsequently. Demographic, blood loss, and transfusion data of the preprotocol cohort were compared with those of the postprotocol cohort. Results In total, 100 children, separated in 2 groups (50 patients each), were analyzed. The mean age at the time of surgery was 8.5 months in the pre-ROTEM-assisted protocol group, and 8.7 months in the postimplementation group. The estimated blood volume loss dropped from 60.8 mL/kg to 49.6 mL/kg after initiation of the current strategy. The intraoperative packed red blood cell (PRBC) transfusion volume decreased from 32.6 mL/kg to 17.1 mL/kg. Administration of PRBCs in the postoperative period also was reduced, compared with the period before implementation of the ROTEM-assisted regimen, from 21.8 mL/kg to 15.9 mL/kg. The average length of hospital stay was reduced from 5.4 days to 4.7 days after use of the ROTEM-assisted protocol. Conclusions As indicated by our results, the use of a ROTEM-assisted protocol is associated with considerable reduction in blood volume loss and perioperative allogeneic transfusion requirements in the surgical management of craniosynostosis with OCVR.

Endoscopic Versus Open Total Vault Reconstruction of Sagittal Craniosynostosis.

This is a retrospective comparative study involving 55 cases of sagittal craniosynostosis, 37 of which has open total cranial vault reconstruction and 18 had endoscopic suturectomy procedure. Preoperative and postoperative 3D photographs of both groups were analyzed and compared. The change in correction between preoperative and postoperative state was measured against a crowd-driven standard for acceptable head shape. Total cranial vault had higher percentage change between pre and postoperative cranial index than endoscopic suturectomy (14.7% versus 7.7%, P = 0.003). However, both techniques were able to achieve the minimum standard of 70% correction (TCV 107.5%, ES 100.4%, P = 0.02). Total cranial vault and endoscopic suturectomy are effective in correcting scaphocephaly among children with sagittal craniosynostosis. Additionally, both techniques are able to achieve a percentage correction that exceeds the 70% benchmark established by the lay public.

Comparison of Head Shape Outcomes in Metopic Synostosis Using Limited Strip Craniectomy and Open Vault Reconstruction Techniques.

Metopic craniosynostosis (MCS), with its trigonocephalic head shape, is often treated with either limited incision strip craniectomy (LISC) followed by helmet orthotic treatment, or open cranial vault reconstruction techniques (OCVR). There is controversy regarding resultant shape outcomes among craniofacial surgeons. Those adverse to LISC claim normal head shape is never attained, while proponents believe there is gradual correction to an equivalent outcome. This study aims to quantitate, over time, the three-dimensional (3D) head shapes in patients who have undergone LISC or OCVR intervention for MCS. Sixty-three 3D images of 26 patients with MCS were analyzed retrospectively. Head shape analyses were performed at: (1) preoperative, (2) 1-month postoperative, (3) 10 to 14 months postoperative (1 year), and (4) 2 years postoperative. Composite 3D head shapes of patients were compared at each time point. Two-dimensional (2D) standardized cross sections of the forehead were also compared. Composite head shapes for both groups were nested, to allow visual comparison as the child's forehead grows and expands. The difference between LISC and OCVR 2D cross sections was calculated; 108.26 mm preoperatively, 127.18 mm after 1-month postoperative, 51.05 mm after 10 to 14 months postoperative, and 27.03 mm after 2 years postoperative. This study found excellent head shape outcomes for both the LISC and OCVR techniques at 2 years of age. It also corroborates the slow and progressive improvement in head shape with the LISC technique. This study highlights the advantages of 3D photography for measurement of contour outcomes, utilizing both 2D vector and 3D whole head analytical techniques.

Endoscopic Versus Open Cranial Reconstruction Surgery for Anterior Craniosynostosis: Experience from South-East Asia

Introduction and objective: Craniosynostosis is a pathological condition resulting from premature closure of cranial sutures. Open cranial vault reconstruction has been the standard of care for isolated non-syndromic craniosynostosis. The current centre introduced the endoscopic craniosynostosis surgery in 2015. The aim of the study is to compare safety outcomes of endoscopic versus open surgery in craniosynostosis within the context of a developing healthcare system, with a focus on anterior synostosis. Methods: This was a retrospective study of all patients undergoing surgery for anterior craniosynostosis from 2012 to 2018 at a single institution. Data on age at surgery, demographics, sutures, surgery duration and complications, including follow up information was obtained. We excluded syndromic patients and patients with pan-synostosis. Statistical analysis was undertaken with P value set at &lt;.05. Results: There were totally 40 patients who underwent craniosynostosis surgery. Seventeen patients underwent endoscopic correction, and 23 open procedures. Metopic and coronal suture patients were equally distributed, with an equal sex distribution. The mean age at surgery in the endoscopic group was 3.7 months (3-5) and higher at 11.5 months (8-18) in the open group ( P &lt; .05). The duration of surgery, blood loss and overall length of hospital stay were significantly reduced in the endoscopic group ( P &lt; .05). In the endoscopic cohort, patients with metopic synostosis obtained complete correction, while patients with unicoronal synostosis had minor residual frontal asymmetry. There were no immediate post-operative complications in the endoscopic group, but the open surgery cohort had minor dural tears in 6 patients. Conclusion: The endoscopic technique has a better safety profile than open surgery for craniosynostosis and results in a complete correction in patients with metopic and bicoronal craniosynostosis.

Infectious Complications After Open Cranial Vault Remodeling for Craniosynostosis.

Surgical site infection (SSI) after open cranial vault reconstruction (CVR), while relatively uncommon, has received little attention in the literature to date. Here, the authors report our institution's experience with the perioperative management of infectious complications following CVR for craniosynostosis and present the first systematic review of the literature on this topic. The authors performed a retrospective chart review for patients with syndromic and nonsyndromic craniosynostosis who underwent open CVR between 1990 and 2015 at a single institution to determine predictors of SSIs and a systematic review of studies that evaluated for SSI after CVR to ascertain the pooled incidence of SSI, common infectious organisms, and prophylactic antibiotic protocols. Out of 548 primary and 163 secondary CVR cases at our institution, 6 primary reconstruction patients (1.09%) and 9 secondary reconstruction patients (5.52%) developed an SSI requiring extended hospital stay or readmission (P <0.001); overall infection rate was 2.11%. Streptococcus and Staphylococcus species were the most common organisms isolated. On multivariate analysis, syndromic status conferred more than 7 times greater odds of SSI (OR 7.7, P = 0.023). Pooled analysis of the literature yielded an overall SSI rate of 1.05% to 2.01%. In contrast to our institutional findings, the most common organisms reported were Candida species and Pseudomonas aeruginosa. The most common prophylactic antibiotic protocol was a first-generation cephalosporin for 24 to 72 hours post-operatively. Patients undergoing secondary reconstruction have higher infection rates after CVR, and syndromic status is an important predictor of infection when controlling for other patient factors. Our literature review reveals nosocomial organisms to be the most commonly reported source of infection, though this is contrary to our institutional findings of skin flora being most common. Antibiotic prophylaxis varies institutionally.

Comparison of different dosage regimes of epsilon aminocaproic acid on blood loss in children undergoing craniosynostosis surgery.

Open cranial vault reconstruction is frequently performed for craniosynostosis. These procedures often involve high volume blood loss that requires blood transfusion. Antifibrinolytics have been shown to decrease blood loss during these procedures but the optimal dose that maximizes benefits is not known. The primary aim was to evaluate the differences in calculated blood loss between a high infusion rate (40mg/kg/h) and a low infusion rate (≤30mg/kg/h) of epsilon aminocaproic acid after a 100mg/kg loading dose. Secondary aims were to determine if a high infusion rate of epsilon aminocaproic acid was associated with decreased packed red cell transfusion volume and to determine the factors associated with blood loss. This was a retrospective study of children who underwent open cranial vault reconstruction. Using an electronic medical record, we identified patients that fit the inclusion criteria. Demographic, laboratory, transfusion, and perioperative data were collected and statistical analysis was performed. Fifty-three patients were included into the study with twenty-three receiving higher infusion rate (40mg/kg/h) epsilon aminocaproic acid. There was a 14.3mL/kg (95% CI 6.6-23.9) decrease in calculated blood loss in the high-dose cohort. An EACA bolus of 100mg/kg followed by an infusion of 40mg/kg was associated with a lower calculated blood loss compared to the group who received 100mg/kg EACA and≤30mg/kg infusion.

Open cranial vault reconstruction in the surgical correction of craniosynostosis. A review of 100 cases

Background: Craniosynostosis, the premature fusion of one or more cranial sutures, occurs in approximately 3,5 to 4,5 out of 10.000 births worldwide. Surgical correction is recommended during infancy for those patients. Different surgical techniques have been employed in the treatment of this condition, ranging from minimally invasive approaches to conventional open procedures.

Cranial shape comparison for automated objective 3D craniosynostosis surgery planning

Virtual planning of open cranial vault reconstruction is used to simulate and define an pre-operative plan for craniosynostosis surgery. However, virtual planning techniques are subjective and dependent on the experience and preferences of the surgical team. To develop an objective automated 3D pre-operative planning technique for open cranial vault reconstructions, we used curvature maps for the shape comparison of the patient’s skull with an age-specific reference skull. We created an average skull for the age-group of 11–14 months. Also, we created an artificial test object and selected a cranial CT-scan of an 11 months old trigonocephaly patient as test case. Mesh data of skulls were created using marching cubes and raycasting. Curvature maps were computed using quadric surface fitting. The shape comparison was tested for the test object and the average skull. Finally, shape comparison was performed for the trigonocephalic skull with the average skull. Similar shapes and the area on the patient’s skull that maximally corresponded in shape with the reference shape were correctly identified. This study showed that curvature maps allow the comparison of craniosynostosis skulls with age-appropriate average skulls and a first step towards an objective user-independent pre-operative planning technique for open cranial vault reconstructions is made.

Surgical Correction of Craniosynostosis. A Single Institution’s Outcome Analysis of 70 Patients

Purpose. The goal of the current study is to provide outcome data for open cranial vault reconstruction at a single institution by a single craniofacial-neurosurgical team. Patients and Methods. A total of 70 patient records were reviewed. The inclusion criteria were patients less than 3 years of age undergoing primary surgery with open cranial vault reshaping and a minimum follow up time of 2 years. Findings. Of the 70 patients meeting the selection criteria (32 female, 38 male), 5 were syndromic and 65 nonsyndromic. Average age and weight were 8.8 months and 9 kg respectively. The oldest child was 21 months and the youngest 3.5 months at the time of surgery. The estimated blood volume lost was 35.8% of total calculated blood volume. Average surgical time was 223.2 minutes. Conclusion. Our review of 70 open repairs of patients with craniosynostosis demonstrates good long-term results with an overall low complication rate and represents open cranial vault reconstruction as a valuable method for repair of such defects.

Abstract 18. A Method for Quantifying Intracranial Volume Change by Distraction Osteogenesis for Craniosynostosis

Purpose: Although numerous publications have described distraction osteogenesis (DO) for craniosynostosis, methods of reporting quantitative results have been inconsistent. Therefore, the efficacy of anterior DO and posterior DO in regards to volume change is not well established. We report a metric that relates volume change to distraction length and our analysis of ICV change by distraction osteogenesis. Methods: Patients with craniosynostosis were treated with open cranial vault reconstruction combined with internal distraction. Preoperative and postoperative CT scans were used to quantify ICV change. Our metric was calculated by dividing percent ICV change by total distraction length. Multiple linear regression was used to identify the impact of distraction approach (anterior vs. posterior), age, time between CT scans, distraction length, and preoperative volume on ICV change. Additionally, we compared our findings to those reported in the literature. Results: Nine unicoronal craniosynostosis patients underwent anterior distraction. Three bicoronal patients and 1 multisutural patient underwent posterior distraction. The average ICV increase was 1.6% per millimeter of distraction for anterior DO compared to 4.2% for posterior DO (p<0.05). On multiple regression, preoperative volume was negatively associated with percent volume change (p<0.05). Posterior approach was positively associated with percent volume change (p<0.05). The volume-length relations from institutional data were greater than those derived from the literature, but not statistically significant. Conclusion: We report relations between distraction length and intracranial volume change for posterior and anterior DO and a comparison to the literature. Additionally, we describe a novel metric for analyzing ICV change achieved by DO.